By Dorothy Brooks
Emergency providers can provide hospital-level acute care to patients at home under Advanced Care at Home, a new program from the Mayo Clinic that leverages technology and in-person services. The approach has been introduced in Jacksonville, FL, and Eau Claire, WI.
- A signature feature is that care for patients at both the Wisconsin and Florida sites is driven out of a command center located on the Jacksonville campus.
- The program is focused on two groups: inpatients who can be discharged earlier, thereby reducing their length of stay, and patients who present to the ED and meet inpatient criteria, but can be safely cared for in their homes.
- Patients admitted to the program do not need ICU-level care or advanced-level diagnostics or procedures.
- Patient stays in the program tend to be prolonged, but providers aim to conserve resources by preventing the need for admission to a skilled nursing facility or a repeat hospital admission.
The Mayo Clinic has unveiled an ambitious new model designed to deliver hospital-level acute care to patients whom program administrators determine can be cared for in their homes safely.
Called Advanced Care at Home (ACH), the model seems ideally timed to respond to the COVID-19 pandemic-related demand for more virtual care options. However, plans for the approach were set in motion in 2019, well before COVID-19 was identified, explains Margaret Paulson, DO, chief clinical officer for ACH in the Mayo Clinic’s Northwest Wisconsin region.
“Dr. [Gianrico] Farrugia, MD, the president and chief executive officer of Mayo Clinic, and his team were planning out the 2030 vision of how they were going to care for our patients in the future, and this idea really rose to the top,” she says. “In other systems, [hospital-at-home models] have been shown to improve outcomes and decrease costs, all while delivering high patient satisfaction. Certainly, at a time when patients are demanding more choices in their healthcare, there were a lot of great reasons why our executive leadership wanted to roll out the project.”
Two Mayo Clinic sites were selected for the initial implementation of ACH: the health system’s Jacksonville, FL, medical campus, which is a destination medical center, and Mayo Clinic’s community specialty system in Northwest Wisconsin, which includes four critical access hospitals and a hub hospital in Eau Claire, WI.
Paulson notes the model went live in Jacksonville in July, and it began serving patients in Wisconsin in August. This gave emergency providers in both regions a fresh option to consider for some patients who meet the criteria for inpatient hospitalization.
A signature feature of the new model is that care for patients at both sites is driven out of a command center located on the Jacksonville campus. “This is a little bit of a nod back to the way that the Mayo brothers practiced 150 years ago where they would do house calls, going to [the homes of] their patients who were sick,” Paulson says. “We can do that now pretty instantaneously with the power of technology.”
To deliver this type of care, Mayo Clinic has partnered with Medically Home, a Boston-based technology company that specializes in innovations designed to help medical providers deliver advanced care in the home. This includes an integrated technology platform as well as a network of in-home services directed by Mayo Clinic providers.
The ACH program is focused on two patient groups, including what program administrators refer to as the “reduced length-of-stay” group and the “acute substitution” group. “Reduced LOS is basically where we identify patients who are already hospitalized and would be appropriate to continue their acute hospitalization in their homes,” Paulson shares. “They no longer need any invasive procedures or testing. They are safe to go home, continue their acute hospitalization in the home, and then transition to a restorative phase.”
Patients identified for acute substitution have been identified in the ED as requiring inpatient hospitalization. However, they are safe to receive their acute hospitalization level of care in their homes through the ACH model. “These patients end up in the ED, and then they go straight to their home for home hospitalization in that acute phase. Then, they transition to the restorative phase,” Paulson explains. “It’s nice for the patients because they never need to be hospitalized in a brick-and-mortar hospital.”
Working a new option into the workflow and processes of the ED can be challenging. To head off any potential problems, the ED was involved early on in the planning for the ACH model. Susan Cullinan, MD, an emergency physician at the Mayo Clinic in Eau Claire, took a leading role in making sure the ACH option would be set up for success in the emergency environment.
“Early on, [Paulson] got my concerns and was willing to work with us,” Cullinan notes. “She included me in the [planning] meetings, and I think that was very helpful so I could give feedback to our ED team as this was coming out and moving ahead. I would talk about it at our monthly ED meetings so that people were aware.”
One big issue involves determining which patients who present to the ED are good candidates for the ACH approach. Cullinan explains potential candidates include patients with a range of diagnoses, such as COPD, bronchitis, heart failure, deep vein thrombosis, pancreatitis, and pneumonia. In general, the program is designed for “sick but stable” patients. However, these need to be patients who meet the criteria for hospital admission. “There are two models in how we get these patients [in the ED]; a push and a pull is how we look at it,” Cullinan says.
For example, under the pull model, the ACH medical team is monitoring all patients in the ED constantly to determine if any meet the criteria. When a potential candidate is identified from the ED tracking board, the ACH team will contact the emergency provider.
Conversely, under the push model, the emergency provider may identify a potential candidate. If so, the provider will initiate discussions with the ACH medical team. “The criteria can be met from their staff looking at our patients or our staff,” Cullinan notes.
Identifying potential candidates for the program mostly is the responsibility of the ACH medical team. This likely will be the case until emergency physicians are more accustomed to the program. In fact, for now, an ACH representative is on site in the ED, and takes the lead on introducing the program to potential candidates.
The emergency provider will see the patient and explain that he or she needs to be admitted. The provider also will explain to the patient that someone from the ACH program is going to be speaking with them. Furthermore, the ACH program is presented as optional, which allows the patient to choose the program or pick a traditional inpatient admission.
While emergency providers always are consulted about potential ACH admissions, it is critical they are not asked to wade through any new processes or steps if a patient elects to receive their hospital-level care at home. “There is a discussion [between the ACH representative and the emergency provider], but I can tell you from the emergency provider standpoint it isn’t any more work to go this route. It is actually probably less,” Cullinan says. “It is as easy a practice as it is to admit a patient to the hospital, and I think that is the key thing. If you make the process more difficult, it is not going to happen.”
When patients identified for ACH agree to this option, they are discharged from the ED, ending their workup in that setting. At this point, an ACH team takes over the patient’s care. This team will arrange for an ambulance ride home and subsequent care. Paulson describes the patients admitted thus far to the ACH program from either the inpatient setting or the ED as requiring inpatient hospitalization, but not needing ICU-level care or advanced-level diagnostics or procedures. For instance, a patient with heart failure may need continued IV diuretics, or a patient may need IV antibiotics for their pneumonia or cellulitis. “Those are patients who can be safely cared for in the home,” Paulson says.
Each ACH patient is equipped with a home kit that includes a blood pressure cuff, scale, and pulse oximetry monitor. “All of those things are Bluetooth-enabled ... so that we can get those vital signs pretty instantaneously,” Paulson says.
However, Paulson stresses the program also relies heavily on providers going into the home, such as nurses, community paramedics, and advanced practice providers. “We can use the technology, but we also have people at the bedside if needed to help facilitate some of those very delicate times when we need a hands-on approach,” she says.
During the acute phase of a patient’s admission to ACH, a nurse practitioner or physician assistant will visit the home on days one and three, although additional visits can be arranged as needed. “The nurses round virtually just as they would in the hospital, but they do that through the technology,” Paulson explains. “If our patients are requiring IV medications, then our command center will help to determine whether they require a nurse for that, or perhaps a community paramedic.”
Make Use of Extra Time
One particularly innovative aspect of the ACH model is each episode of care is prolonged. “We have the luxury of time. Our length of stay tends to be on the 30-day average rather than the four or five days a patient would typically spend in the hospital,” Paulson says.
This period includes both a patient’s acute phase and what Paulson refers to as the restorative phase. “This ... gives us time to help with strengthening, patient education, and with ensuring that the patient has become completely independent in their care, or as independent as they can be,” she says.
Throughout an ACH episode a patient’s primary care provider (PCP) is encouraged to be involved. Toward the end of the episode, ACH care managers will set up an appointment with the PCP before discharge.
“That gives the PCP a warm handoff so that [he or she] understands what has happened during the stay,” Paulson says. “If the PCP feels comfortable, then we arrange for discharge [from ACH]. If there are things that still need to be worked on, then we can hold on to the patient a little longer.”
With such long episodes of care in the ACH program, how does the program conserve resources?
“The patients who benefit most from this model are patients who are older, they are deconditioned, and they would ordinarily end up in a skilled nursing facility following their acute inpatient hospitalization,” Paulson explains. “That is where we can save money, if we can prevent a skilled nursing facility admission or if we can prevent a readmission.”
Paulson reiterates that patients in the ACH program have more time to recover while they are monitored closely for their care needs. “A lot of patients need that time,” she says.
For example, Paulson notes that discharge from an inpatient hospitalization typically is a rushed time. Even though providers try to make sure patients receive all the education and follow-up appointments they need, many just feel overwhelmed.
“With this program, instead of giving patients a handout on what reducing their salt intake looks like, we can work with them,” Paulson notes. “They invite us into their home, sometimes through video and sometimes in person, but we can work with them.” During in-person visits, a clinician might inspect a patient’s refrigerator or pantry to make sure someone with heart failure understands which foods he or she should avoid. “Through that educational period, we hope that readmissions to the hospital can be avoided,” Paulson says.
Paulson acknowledges admission to the ACH program is limited to patients with certain types of insurance. “We are working with individual payers to try to create bundled agreements,” she says.
While not all payers are on board with this approach yet, ACH is available to a large population of patients within an accountable care organization in the region. The health system is continually working to add additional payers to the mix so that more patients can access it.
Take It Slow
In the first three months of the ACH implementation in Wisconsin, roughly 18 patients were enrolled. “We have been intentionally slow because we learn a lot with every admission,” Paulson observes. “There are a lot of things we can work on to make things better for the next patient.”
While there are not enough data to report on outcomes or financial returns, the program has made some progress. “Patients have been overwhelmingly supportive of the model. They are really happy that they are not in the hospital and that they are not in a nursing home,” Paulson shares. “Our first three patients cried because they were so happy they didn’t have to be in the hospital and were able to go home.”
ACH’s first patient was a man who had been hospitalized 10 times in the previous 12 months for exacerbations of heart failure and COPD.
“When he got home and I was on a video visit with him, his two dogs, Skittles and Roosevelt, were by his side. He had a big smile on his face. He was just so happy to be in his home environment, able to sleep in his own bed, and have his family visit,” Paulson reports.
The second patient enrolled had undergone spine surgery and needed a prolonged period of IV antibiotics.
“He was a gentleman who had been in the hospital a few times before and had become delirious. This hospitalization was no exception,” Paulson notes. “He had his surgery, did really well with that, but became delirious.”
The patient’s medical team looked at all the angles and found no other source of the delirium.
“This was someone who we identified could be safely cared for in the home. We talked with his surgeon as well as his family, and they were very excited about him going home.”
Otherwise, the patient probably would have spent a few more days in the hospital before transferring to a facility 40 miles away. The family did not want to go through that. “When the patient got home, within a few hours his delirium resolved. It was just stunning,” Paulson recalls. “He and his wife were over the moon about the program.”
In the early days of the ACH program, the focus was on identifying hospitalized patients who could return home early, thereby shortening their LOS. Now, there is a growing focus on the acute substitution group — patients who are identified in the ED as meeting criteria for an inpatient admission, but can be safely cared for at home.
“We have had two patients so far from the ED that have been admitted [to the ACH program] with COPD, both of them in their 70s,” Cullinan says. Further, she notes both patients and emergency providers seem comfortable with the option.
In fact, no patient has declined the option thus far. The emergency providers’ program acceptance can be attributed in part to multiple simulation sessions. This helped staff understand how patients would be identified and admitted to the ACH program.
“The multiple sessions helped with different providers,” Cullinan says. “We talked about it, too, with those providers who weren’t actually available at the time [of these sessions]. But even if they weren’t part of a simulation session, this is very easy ... because there are not a lot of extra things to do.”
Including the ED in the early planning sessions and asking ACH administrators to strongly advocate for the program have been significant keys to the smooth implementation of this option in the emergency setting. In addition, Cullinan sees opportunities to further strengthen the program once the surge in COVID-19 patients eases.
“We have case managers in the ED who were pulled at one point to do more work in the hospital,” she says. “But I think once we can get them back in the ED, they will be advocates, and they can help us look for [potential] ACH patients.”